Keynote Plenary Speaker Application 120712

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Keynote Plenary Speaker Application 120712 Powered By Docstoc
					                    American College of Health Care Administrators
                          Call for Keynote/Plenary Speakers

Our goal is to provide advanced leadership education. Keynote and plenary speakers should address
topics that are relevant to long term care leadership education.

The College represents administrators and other executives across the continuum of long-term healthcare
and aging services. Winter Marketplace draws approximately 250 attendees and the Convocation draws
about 400 attendees. Conference participants include facility administrators, chief executives, owners,
presidents, corporate managers, directors of nursing, academics and educators, consultants, researchers
and other leaders (and future leaders) in health services administration. The Summer Leadership
Conference draws approximately 35 long term care executives. Our audience is experienced and
knowledgeable and expects current and relevant leadership information.

Speaker Name          Credentials (PhD, MBA etc.)



Street Address

City       State        Zip

Email (required)       Cell

At which ACHCA Conference(s) are you interested in presenting?

   Winter Marketplace 2012, November 29-December 2, 2012, Las Vegas, NV

   Convocation 2013, April 12-16, 2013, Orlando, FL

   Summer Leadership, July 29-August 2, 2013, Bermuda – (At this conference, a single speaker
presents the entire 15 hour workshop for executive long term care administrators. The speaker is
reimbursed for travel expenses for himself/herself and spouse. However, no additional honoraria is
paid for presenting this workshop.)

What is your honoraria for a one hour keynote/plenary presentation? (Required)
What additional travel expenses should we anticipate covering?

Are you willing to teach any additional sessions if you are chosen as a keynote/plenary? If yes, please
indicate below your requirements.

Biosketch – This biosketch should be no more than 100 words in length. The first sentence should start
with your full name and credentials. Then, include your current position and current company. Please
complete the remainder of the paragraph describing job responsibilities or past honors. Be sure you
mention any experience with long term care administration. (Do not simply refer to your website)

Presentation Topics

     1. (preferred)

Three Objectives for Preferred Presentation (#1 above) Complete this phrase for each objective, after
completing this session participants will be able to…


Description of Preferred Presentation (#1 above) (<100 words in paragraph form)

Professional References
Please include 3 professional references. These references should have knowledge of your presentation
style and successes.

    1.   Name             Title


         Phone          Email

    2.   Name             Title


         Phone          Email_

    3.   Name             Title


         Phone          Email

                             Please submit this form to

You will be notified five months prior to each conference via e-mail regarding the results of the
keynote/plenary selection process. . If you have any questions about the completion of this form,
please contact Janet Spence, ACHCA Director of Education and Professional Advancement, by email at or by phone at 202-536-5120.

            Thank you for your interest in the American College of Health Care Administrators.

If you are selected as a keynote or plenary speaker, you will be asked to submit a detailed outline of
your presentation, possibly additional objectives, signed contractual letter, disclosure statement, and
audiovisual requirements. Please sign below to indicate that if you are selected to present you will
submit all required documentation within one month of being notified.



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